| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
167 |
165 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
116 |
115 |
$3K |
| D8670 |
Periodic orthodontic treatment visit |
13 |
13 |
$3K |
| D1351 |
Sealant - per tooth |
46 |
18 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
79 |
78 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
33 |
19 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
47 |
47 |
$968.30 |
| D0220 |
Intraoral - periapical first radiographic image |
142 |
141 |
$777.80 |
| D0274 |
Bitewings - four radiographic images |
46 |
46 |
$692.90 |
| D0230 |
Intraoral - periapical each additional radiographic image |
147 |
141 |
$676.40 |
| D2140 |
|
15 |
12 |
$462.75 |